HomeMy WebLinkAboutCertificate of Insurance - BLDX-23-15545 22206sb-\The Commonwealth of Massachusetts
D ep artme nt of I n d ustr ial A cc identsI Congress Street, Suite 100
Boston, MA 0Zll4-20 t 7
\\:orkers, compensation ,,.,.".""'##;frfl,ii?rl!.!;'Ja,,r,^"r",,/Erectricians/plumbers.
TO BE FILED WITH TIIE PERMITTING .{ITTHORITY.icant o on
Name (B usiness/Organization {rld.ividua.l) :
PI ea e tL
City/State/Zip:
Any applicar! tha! check box #l must also fill o
Phone #:'Jaa g e
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ut the section below showing their workers' cornpensation policy info.mariofu
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Type of project (required):
New construction
Remodeling
Demolition
Building addition
Electrical repairs or additions
Plumbing repairs or additions
i3.fl.Roof repairs
14 fl Other
Hooeowners who submit lhrs aifidavit indicari ng thry are doiag all work and rtrenlcontractors tiat check this box must atEched an additional sheet showing lhe l1ameernployees. If the sutEconE-actors have employees, they roust provide their worke$'
hire outside cont-actors must submit a new affidavit indicating suclL
of the sub-contrdctors and statc whether or oot lhosc entities liave
comp. policy number.
Ar. you an cmploy.r? Ch.ck the appropriate bor:
l.f| I am a employer with _cmployees (fuIl and/or parr_rime). +
21$1am a sole proprietor or parbership and have no employees working for me inany capacity. [No worken' comp. insurance required.]
I am a homeowner doing all work myself [No worke6, cornp. insurance rcquiaed.]i
i am a horoeowner and will be hiring conrEctors to conduct all work on my prope.ty. I willensure that all conu-actors eithcr have worlicrs, compcnsation insuranc; ";;; ;[ -
proprietoas with no .rnployees.
I am a Bencral conu.actor and I have hired thc sub-con!-actors lislcd on the anachcd sbeerThcsc sub-contactos have cmployees and hav" *ork"rs, "ornt. ;;"" , *- *
6 ! we arc a corporation and ils officcrs have exerc^ed ther nght ofexempton Dcr MGL c152, g I (4), and we ha,re no rmployees. Ilto *ort.", "o.plnrurun"" [iui.IJ.]
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I am dn emploler thal is providing y,orkers, coinformation
Insurance Company Name:
mpensation insurance for my employees- Below is the poliqt and job site
Policy # or Self-ins. Lic. #
Job Sire Ad&ess:_
o,,,.0 , "oo, or il'liil*_". * *,.r., *.,Failure to secure cover€e as required. under MGL c. 152, $25A is a criminal violation punishable by a fine up to $ I,500.00and'/or one-year imprisonment, as well as civil penatti.s in L" tona of a STop woRrbnopR ania fine of up to $2s0.00 aday against the violator. A copy of this statement *"y b; {b;;;; to the office of [nvestigations of the DrA for insurancecoverage verification.
I do hereby cetiJy under the pains and.penalties oJ peiury that the information provided above is trud and correcl.
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Phone#,>a 4a z-7 La 6z*
o notwrite in thb area, to be completed b) city or town offciat
l. Board of Health 2. Building Department J. Ciry/Town Clerk6. Other 4. Electrical Inspector 5. plumbing Inspector
Phone #:
OfJicial use only. D
City or Town:PermiVLicense #
Contact Person:
Issuing Authority (circle one):
:
Address:
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